LETTER TO THE EDITOR An Underestimated Complication of Atrial Fibrillation Ablation: Gastroparesis

To the Editor: We read with interest the article by Wasserlauf et al.1 published recently in Pacing and Clinical Electrophysiology Journal entitled “Cryoballoon versus Radiofrequency Catheter Ablation for Paroxysmal Atrial Fibrillation.” In this article, while the authors were comparing the outcomes of cryoballoon (CB) versus radiofrequency (RF) catheter ablation for paroxysmal atrial fibrillation (AF), they concluded that the overall complication rates were equivalent between two modalities; however, fewer cardiac perforations occurred with CB ablation. In our recently accepted study, (11th International Congress of Update in Cardiology and Cardiovascular Surgery), we aimed to define the factors associated with the occurrence of gastroparesis in pulmonary vein isolation (PVI) procedure by using cryoenergy or RF energy. The study population consisted of 74 consecutive patients who randomly underwent PVI with CB (58 patients) or RF technique (16 patients) for drug refractory paroxysmal AF. We added 16 new consecutive patients who underwent PVI by using RF ablation in this study population. Finally, a total of 90 patients were evaluated. Gastroparesis was suspected in patients who had symptoms like epigastric discomfort, abdominal pain, heartburn, bloating, nausea, or vomiting during the procedure and those patients were assessed by fluoroscopy. The diagnosis of gastroparesis was considered if the fluoroscopy shows an air-filled stomach or air-fluid level in the fundus of an enlarged fluid-filled stomach (Fig. 1). Abdominal x-ray was also performed for the patients describing the similar symptoms after the procedure. If there are the findings of gastric hypomotility on fluoroscopy during the procedure or abdominal x-ray after the procedure, the diagnosis was confirmed with gastric emptying scintigraphy. A total of six patients (10.3%) had gastroparesis-related symptoms in the CB group. In four of six patients (6.8%), the symptoms emerged

during the procedure and a presumed diagnosis of gastroparesis was done by fluoroscopy. The other two patients admitted to our outpatient clinic with prolonged symptoms of gastric delayed emptying at three days and four days after the procedure. Abdominal x-ray showed an air-fluid level in the fundus of an enlarged fluid-filled stomach. Gastroparesis was seen in only one patient after RF ablation. In detailed analysis of the patients with gastroparesis, the procedure time and energy delivery duration were comparable for the patients with and without gastroparesis. However, mean minimal temperature was lower in the patients with gastroparesis than without (in left interior pulmonary vein [LIPV] –55.3 ± 4.8°C vs –47.2 ± 2.7°C, P < 0.0001, in right interior pulmonary vein [RIPV] –50.3 ± 1.5°C vs –44.8 ± 3.3°C, P < 0.0001, respectively). Also, left atrial diameter was smaller (36.8 ± 1.9 mm vs 41.9 ± 4.6 mm, P = 0.002) in patients with gastroparesis. The predictive abilities for gastroparesis of mean minimal temperature on LIPV and RIPV were optimal (area under the curve [AUC]: 0.958, AUC: 0.935, respectively). The sensitivity of mean

Figure 1. Fluoroscopic view of enlarged and airfilled stomach. Panel A demonstrates early phase of gastroparesis, whereas panels B–F show progressive gastric enlargement due to decreased peristaltic activity.

doi: 10.1111/pace.12607

©2015 Wiley Periodicals, Inc. PACE, Vol. 38

May 2015

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minimal temperature ࣘ–52.5°C for predicting gastroparesis was 83% with a specificity of 95%. The sensitivity of mean minimal temperature ࣘ–48.5°C for predicting gastroparesis was 83% with a specificity of 89%. Lower temperatures in inferior pulmonary veins by CB and small left atrium size were associated with increased risk of gastroparesis. Our study might be hypothesis-generating and asking for further prospective and larger studies evaluating the total rate of gastroparesis after second-generation CB ablation.

TOLGA AKSU, M.D., ¨ ¨ TUMER ERDEM GULER, M.D., SERDAR BOZYEL, M.D., ¨ ¨ ¨ S ¸ UKRIYE EBRU GOLC UK, M.D., ˙ and ISMAIL ERDEN Department of Cardiology, Derince Training and Research Hospital, Kocaeli, Turkey [email protected]

Reference 1. Wasserlauf J, Pelchovitz DJ, Rhyner J, Verma N, Bohn M, Li Z, Arora R, et al. Cryoballoon versus radiofrequency catheter ablation

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for paroxysmal atrial fibrillation. Pacing Clin Electrophysiol 2015; 38:483–489.

May 2015

PACE, Vol. 38

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An underestimated complication of atrial fibrillation ablation: gastroparesis.

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